Beinvenidos a nuestra
clinica
Initial Visit Form
GENERAL INFORMATION (all clients fill out)
Informacion del Paciente:
Apellido
nombre
secundo nombre
Fecha de hoy
Domicililo (No PO Box)
Como sabes de nosotros
Ciudad
postal
estado
codigo
Telefono de casa
Numero de securo social
licensia
sexo
H M
numero de
estate matrimonial
fecha de nacimiento
Soltera casado Div. viuda.
Telefono de trabajo/ cellular
Nombre de contacto de emergencia
Correo electronico
Numero de telefono de emergencia
Informacion de la asecuranca:
Nombre del asugurado
fecha de nacimiento
Fecha que te lastimaste (fecha del accidente)
Tu relacion con el asugurado
Poliza #
Claim # / ID #
Nombre de la compania aseguradora
Que tipo de lastimadura /accidente (escoje uno)
trabajo
Reclamacion al seguro/direccion pare la factura
accidente vehicular
otro (explique por favor):
Ciudad
Estado
Zona postal
Historial Medico (all clients fill out)
 Cuando fue tu ultimo examen fisico? ____________Quien
_______________________
no me acuerdo cuendo fue mi ultimo examen fisico
te
lo
hizo
?
 Has tenido un accidente previo/trauma/caidas?
Si/ No/ no me acuerdo
fecha:
_____________
Esta problema resulto? SI/ No ( si circulas si , no conteste la #3)
Si es No, tienes los o similares condiciones? SI/ No/ no me acuerdo
Si contesta SI, esplique alguna differencia de intensidad/ frequencia/ duracion del dolor
que sientes actualmente :__________
1
 Explica cualquier hospitalacion previa: ____________________ no me aguerdo de
hospitalacion previa
 Has tenido sirugias antes? Si/ No/ no me acuerdo
Que
tipo(s)
y
la
_________________________________________________________
fecha(s)?
 Te has lastimado en trabajo previamente?
SI/ No/ no me acuerdo
fecha:
_______________
Esta esto resulto? SI/ No ( si circula si, ve a la pagina 2: Jefe queja/dolencia)
Si contesta No, tienes el mismo o similar condicion? SI/ No/ no me acuerdo
Si contesta SI, explique alguna diferencia de intensidad/frequencia/duracion del
dolor que sientes
actualmente:___________
Name: _________________________Date: ________________Claim Number:
___________________
CHIEF COMPLAINT (all clients fill out)
Notas: Rango 1-10 key: 1-4 = suave, incomodo; 5-7 = angustiante; 8-10 = intenso,
insoportable
 Marca todos lo que aplice. Tu experimentas:
Dolor de cabeza- a donde: dolor cara(784.0) toda la cabeza frente atras de
cabeza ojos
temple lado derecho lado izquierdo
otros:_________________________________________________
intensidad:
(de
1-10):_______
________________________________________________
Cometarios:
Dolor cuello- a donde: brota hacia arriba en espalda lado derecho brota hacia arriba
en espalda lado isquierdo
arriba/abajo mas de lado derecha mas de lado izquierdo irradiar en la cabeza (723.2)
dolor cuello(847.0) otros:_______________
Intensidad:
(de
1-10):_____
Comentarios:
________________________________________________
Dolor hombro - adonde: lado izquierdo lado derecho los dos lados
intensida:
(de
1-10):_______
________________________________________________
Comentarios:
Dolor espalda media- a donde: toda la espalda media mas el lado derecho mas el
lado izquierda
2
brotar al rededor del pecho radiating a la cabeza(724.4) irradiar a los brazos/piernas
(724.4)
otros:___________________________
Intesidad:(de1-10):_______
Comentarios:________________________________________________
Dolor espalda baja-:a donde toda la espalda baja mas al lado derecho mas al
lado izquierdo
se dispara al brazos/piernas
otros:
_______________________________
Intensidad:
(de
1-10):______Comentarios:
________________________________________________
Dolor Cadera/pelvis -: a donde caderas Pelvico
lado izquierda lado derecho
dos lados
Intesidad:
(de
1-10):_______
________________________________________________
Comentarios:
Dolor brazos/piernas-: a donde brazo izquierdo brazos derecho dos brazos pierna
izquierda pierna derecha dos piernas
Intensidad:
(de
1-10):______Comentarios:
_________________________________________________
Dolor en el Tobillo- a donde: tobillo izquierdo tobillo derecho dos tobillos
Intensidad:
(de
________________________________________________
Otro:________________-
Donde
______________________________________
Intensidad:
(de
________________________________________________
Name: _________________________Date:
________________
1-10):_____Comentarios:
espesificamente:
1-10):_____Comentarios:
________________Claim
Number:
 Lista cualquier medicamento que estes tomando y esplica cualquier efecto
segundario: No aplica Insulina Cortisona patillas pare nervios
Antidepresibos
Shoe lifts
medicamento para presion alta
Vitaminas/suplementos
Aspirina- que tan sequido? ____________
pastillas para dolor/relajante
de musculo
Algun
efectos
secundarios
:
3
____________________________________________________
C.: sientes a dormecidos o cosquillero piernas /pies pierdes tu balance
sientes a dormecidos o cosquillero brazos no aplica
 Possible sintomas /dolor de mandivula. Marca los que aplican:
dolor oido, dolor, pica, dolor afilado sonar en el oido mareo
problemas
de los dientes
cara entumecida rechinas lo dientes en la noche
dolor en articulacionde mandibula o clic sientes tu oido lleno, tapado
otro-explicar por favor:
_________________________________________________________
no aplica
E. sintoma relacionado con posible cerebro and brainstem. marque todos que a
aplica:
problemas con/largo o corto term memory problemas
para
concentrarte
agravar/ molestar con ruido
anciedad
depresion
irritable
problemas para dormir fatiga problemas sexuales
cambio en gusto o oler otros- por favor explicar:
___________________________________
no aplica
 Cuanto tiempo/regularmente tienes o sientes dolor?
todo el tiempo
durante el dia durante la noche mas de 6 horas menos
de una hora
in
intervals-how
long
each
time?
_______________________________________________
otropor
favor
explique:
______________________________________________________
 Que hace dolor mejorar ?
aspirina
movimientoa
que
______________________________________
caliente
hielo
masaje
relajante
de
descansar
expansion
descansar en cama
elevacion
nada
otro-por
favor
________________________________________________________

direccion:
musculo
explique:
Describi cualquier actividad que haga tus simtomas peor:
__________________________________________________________________
_________
 Cueando
y
como
empeso
el
dolor
:
_______________________________________________
4

J.
Describi
cualgier
informacion
adicional
sobre
tu
condicion:
_____________________________________________________________________
__
 El accidente / lastimadura en peso el dolor hace mas de dos semanas? Si / No
Si es si , por favor explique por que no vino antes de dos semana:
_______________________
__________________________________________________________________
_________
Name: _________________________Date:
____________________
________________Claim
Number:
Ensene las areas que siente dolor / siente sensaciones diferente o nousual
Marca la area en este cuerpo donde tu sientes la sensacion describir. Usa los simbolos
apropiados. marca la area de radiacion (pain that spreads). Inculle todas las areas
afectadas.
entumecido ardor
Agujas
dolor
-------######
0000000
xxxxxx
-------######
0000000
xxxxxx
-------######
0000000
xxxxxx
Por favor marque del cero a 10 la intensidad del dolor que siente
peor dolor que ayas sentido con esta condicion
Pain Chart
5
doler
apunalar
******
////////
******
////////
******
////////
con su condicion. 10
Dolor cuello-espalda-brazos
On a scale of zero to 10, I rate my
Discomfort as follows
(_________________________)

10
dolor
No
dolor severo
Dolor
espalda media
On a scale of zero to 10, I rate
my
Discomfort as follows
(_________________________)
0
10
No dolor
severo
dolor
Dolor
6
Espalda
baja y
piernas
On a scale of zero to 10, I rate
my
Discomfort as follows
(_________________________)
0
10
Nodolor
dolor severo
Fecha:_________________
_X______________________________
Firma:
SYSTEMS REVIEW
NAME:___________________________________________
___________________________
DATE:__________________
CLAIM
NUMBER:
Por favor revise las siquientes condiciones. Si as tenido alguna condicion en le pasado marque en la columna 1. Si tienes la condicion
ahora marque columna 2.
pasado
pasado
ahora
GENERAL
pasado
ahora
GASTRO-INTESTINAL
780.6
calen
783
Poco apetito
780.9
refriedo
536.8
Pobre digestion
780.8
Sudor noche
994.2
Hambre excesiva
780.2
desmayarse
787.3
eructar o Gas
780.4
mareo
787
Nausea
780.3
Convulsions
787
Vomito
780.52
Perdida de sueno
578
Vomitanto sangre
780.7
cansancio
536.8
Dolor sobre estomago
799.2
nerviosismo
564
estrenido
783
Perdida de peso
558.9
Diarrea
782
dolor/miembro entumecido
789
Problema del Colon
995.3
alergia
786.09
resoplido
455.6
Hemorroides/Piles
729.2
Neuralgia
785.1
problemas del higado
782.4
Piel amarilla
575.98
problemas del vejiga
786.2
mentruasiones dolorosas
ahora
sangre en Stool
OJOS,OIDOS,NARIZ,GARGANTA
368.9
Pobre vision
378.9
Ojos cruzados
pasado
7
ahora
SOLAMENTE MUJERES
pasado
379.91
Dolor en ojos
626.2
689.9
sordera
626.4
Ciclos Irregulares
388.7
Dolor de oidos
627.2
388.3
Ruido en oidos
625.3
calores
calambre/dolor
espalda
388.6
oido Discharges
634.6
aborto
478.1
Obstruccion nasal
623.5
Flujo blanco
784.7
Sangrado
nariz
de
embarazo
462
784.49
Garganta adolorida
Ronco
477.9
Fiebre heno
793.9
Asma
ultimo Papanicol fecha:________________________
Fecha que comenzo tu ultimo periodo:____________
pasado
ahora
MUSCULO O JOINTS
debil
460
Refriado frecuente
240.9
Engrosamiento tiroides
719
hinchado Joints
463
amigdalitis
781
temblor
686.9
Problema senunitis
729.5
Problema
CARDIO-VASCULAR
724.79
Hueso tail dolorosa
ahora
Twitching
pies
783
Corazon rapido
724.5
Dolor entre
427.89
Corazon despacio
553.9
401.9
Presion alta
737.3
Hernia
Columna
Curvature
458.9
Presion baja
786.51
Dolor sobre corazon
368.9
438
Problema del corazon
698.9
picason
719.07
Hinchazon en tobillo
287.8
Moretones facilmente
459.9
Mala circulacion
701.1
seca
pasado
ahora
436
hombro
vertebral
PIEL O ALERGIAS
Vena varicosa
pasado
Flujo excesivo
erupcion piel
furunculos
Derrame cerebral
782
Piel sencible
GENITALES-URNIARY
708.9
urticaria/Alergia
788.3
Orinar frecuentemente
692.9
Eczema
788.1
Dolor al orinar
599.7
Sangre en orin
ahora
592
Infeccion en rinon
788.3
Mojas la cama
788.1
No control orinar
601.9
Problema de prostata
SYSTEMS REVIEW
NAME:___________________________________________
DATE:__________________
8
CLAIM
NUMBER:
_______________________________
Por favor revisa as siquientes lista de condiciones. Si as tenido alguna condicion en el pasado marca la columna 1. Si tienes alguna
condicion ahora marca la
columna 2.
pasado
ahora
N/A
HABITOS
pasado
ahora
RESPIRATOR
Fumas______Paquete(s)/dia
786.2
Tos Chroni
Alcohol______tomas(s)/dia
766.3
escupir sa
Café_______taza(s)/dia
933.1
escupir fe
No ejercisio
786.5
Dolor en P
Moderado ejercisio
786.09
Dificulta
Rinon
Cancer
Diario ejercisio
Comes bajo en sal/dieta
grasa
Tienes una dieta
balanciada
Estresado en casa/trabajo
HISTORIAL FAMILIAR
Diabetes
Madre:
vive
fallecido
(circule uno)
Padre:
vive
fallecido
(circule uno)
Hermanos:
cuantos? _________
Hermanas:
cuantos? _________
Corazon
e
MARGUE SI AS TENIDO ALGUNA DE ESTA ENFERMEDES:
541
Apendicitis
285.9
varicela
541
neumonia
285.9
Anemia
541
Fiebre reumatica
285.9
Sarampion
541
Polio
285.9
paperas
541
Tuberculosis
285.9
Diabetes
541
Tos ferina
285.9
Cancer
429.9
Enfermeda del corazon
716.9
Artritis
429.9
Buche,bocio
716.9
Epilepsia
429.9
gripe
716.9
Desorden M
429.9
pleiritis
716.9
Lumbago
429.9
Alcoholismo
716.9
Eczema
429.9
LISTA SI TIENES ALGUNA ALERGIAS:
Enfermedad venerea
N/A
9
Name: _________________________Date:
___________________
________________Claim
Number:
Informacion sobre accidente vehicular (MVA clients solamente)
 Fecha del accidente:_____________: Numero de carros involucrados en el accidente:
________
 Auto que estabas: Año: ______ Marca: ___________Modelo: ___________
Dano: menor mayor total aprox. $ ________ valor
 Eras tu el dueno del carro: Si/ No
 Otros auto(s): Año: ________ Make: ________
Modelo: ________
 Calle/Interseccion
____________________________________________________________
Ciudad/Estado: _________________________
Nombre(s):
 fue: interseccion
luz/signo de para (circule uno)
no interseccion
si fue en la luz, estaba:
verde rojo amarillo
felcha para doblar
la superficie estaba: seco mojado lizo heilo gravilla
otro:
____________________________
 Que tan rapido y en que direccion iva tu carro moviendo cuando pego/pegaron?
________________________________________________________________________
___________
 Que tan rapido y en que direction estaba el otro carro moviendo cuando te pego?
________________________________________________________________________
___________
 Donde estabas sentado en el vehiculo?
manejador
pasajero enfrente
pasajero atras izquierda/derecha/centro
(circule uno)
atras en la cama de truca
manejador de motocicleta/pasajero (circule uno)
otro-por
favor
esplicar
:
________________________________________________________________
 Como estaba tu cuerpo posicionado al tiempo del acidente?
10
mirando hacia abajo asiendo algo mas mirando al trafico viniendo
mirando al pasajero
mirando a enfrente
doblar a la izquierda/derecha (cirgule uno)
mirando a traffico oncoming
mirando por el espejo rear view
mirando al manejador
otro-por
favor
explique:
________________________________________________________________

En que areas de tu carro le pegaron ?
enfrente lado de la esquina manejador esquina trasera al lado manejador
lado
del manejador
enfrente esquina pasajero esquina trasera del pasajero
lado pasajero
defense delantera
defense trasera
trasera trailer
collision de frente
total
otro: ______________________
 habia otro secundo impacto? Si/ No
________________
Si, a donde fue el impacto en tu carro?
 Mi cuerpo pego el
volante
respaldo
paneles de al lado
asiento con mi pecho/abdomen/cabeza/cara (circulo
uno) tablero
puerta
atras del asiento del manejador
pavimento
consolar
otro-por favor explique:
________________________________________
Name: _________________________Date:
________________
________________Claim
Number:
 Las siquientes parte de mi cuerpo fueron golpiadas: cara frente nariz cuello
hombro brazo mano muneca dedos pello abdomen cadera muslo rodilla shin
otro- Por favor esplique: __________________________________

Descripcion adicional del acidente:
_____________________________________________________
________________________________________________________________________
_______________
 Huvo un aviso antes del impacto?Si/ No
 Se desplego la bolsa de aire?Si/ No
 Tiene tu carro respaldor? Si/ No
11
 Como resultado del accidente estuviste:
indefenso/incosciente aturdido
no puedes mover ciertos partes del cuerpo-por favor explique que partes y porque:
___________________________
moreton o sangrar (Porfavor describer lesion):
_______________________________________________
conmocionado pero puedo funcionar si pudo parar/fuera del carro y caminar no muy
preciso sobre lo que sucedio
 Si te acuerdas haberte golpiado la cabeza? no me acuerdo de haberme golpearme la
cabeza
Si, me acuerdo de golpearme la cabeza No, me golpie la cabeza
Siquiendo el accidente:
 Estaba el personal de emergencias en la escena? Si/ No
 Te llevaron a el hospital cuarto/ habitacion de emergencias? Si/ No
Si, nombre del hospital: _________________Que areas te comprobar/trataron?
_________________________
 Tu hiciste sequimiento con el tratamiento para tus heridas? Si/ No
Si
,
en
cual
hospital?
____________________________________________________________________
 Te
tomaron
rayos
x?Si/
No
Si,
__________________________________________
Por quien? ________________________
Tu reportaste el accidente con tu compania de seguro?
que
parte
Si
No
del
cuerpo?
 Tu tienes un abogado que te represente por este accidente ?
Si
No
Si, por favor proporcionar los siguientes para nuestro registros:
Nombre del abogado: ____________________________________ telefono #
_______________
Direccion del abogado:
_______________________________________________________________
ciudad/estado/zona postal :
_______________________________________________
Name: _________________________Date:
____________________
12
________________Claim
Number:
Consentimiento para tratar & Acuerdo financiero (por favor leer y firmar)
Yo comprendo completamente que Yo soy reponsable directamente/completamente por todos los cargos
la clinica, contraer por servicios hechos a mi, y que este arreglo esta hecho unicamente para proteccionde
clinica I en consideracion contingete de cualquier resolucion, fallo o veredicto por cual yo pueda finalmen
recuperar. Yo soy la persona responsible por la factura, a pesar de cualquier resultado de reclamo/cau
legal.
Yo autorizo a mi compania de seguero que hago pagos directamente a esta oficina. El doctor no se
reponsable por niguna condicion medica diagnosticada pre-existente.
Nosotros llamaremos para verificar elegibilidad y benefios como cortesia a nuestros pacientes. Com
la poliza del seguro es un contrato entre el pacient y la compania de seguro, Nosotros no podem
garantizar estos beneficios. Cualquier cantidad que la compania de seguro no cobra pasara hac
responsabilidad de el paciente, a pesar de todo de alguna reduccion, negacion o arbitrar
determinacion de honorarios habitual /acostumbrado. Nosotros aconsejamos/ asesoral nuestr
pacientes que verifique su propio seguro.
En orden para tener privilegio/honor para facturar el seguro prorrogada a mi,Yo entiendo que yo ten
que: reportar mi accidente ala compania de seguro de auto a la oficina de reclamos y proporcionar a
compania de seguro de auto con toda la solicitud necesaria PIP (Personal Injury Protection) (personal lesi
proteccion).
Yo e leido, comprendido,y estoy de acuerdo con el contrato sobre finansamiento declarado arriba.
__________________
fecha
____________________
fecha
X________________________________________________
firma de los padres, //guardian legal para pacientes menores de 18 anos
________________________________________________
firma del testico
13
Name: _________________________Date:
____________________
________________Claim
Number:
Una cita es un compromiso de ti mismo y el doctor que hizo a un lado tiempo para tratarte. Por lo ta
Nosotros pedimos/ solicitamos que nuestros pacientes nos informen por lo menos 24 horas adelantado cua
quieran cancelar o volver a programar una cita , para que nosotros podemos hacer la cita disponible para qu
lo necesite.
Nosotros reservamos el derecho de cobrar la cantidad de $25.00 por citas perdida, a esos pacientes
pierden sus citas sin notificarnos o informanos o quien cancele/ volver a programar una cita con menos de
horas de aviso. Esta cuota/honorarios no esta cubierto por seguro y necesita ser pagado por el paciente.
Para no inconvenier a los que llegan a su cita a tiempo, los que llegen tarde van a recibir cortos/reducid
tratamiento y la cuota regular del tratamiento. Para aquellos que llegen atiempo para su cita seran atendi
primero.
Tambien, nosotros no somos responsable por articulos personales perdidos/robados. Nosotros no som
responsable por los ninos o cualquier nino que pueda estar contigo durante tu visita. Nosotros no som
responsable por ninguna lesion que pueda occurrir en casa por hacer los ejercicio que el medico te dio.
Nosotros valoramos tu negocios y asegurar que nosotros estamos disponible para ti cuando nos necesi
Gracias.
Yo comprendo y estoy de acuerdo con lo de arriba:
X________________________________________________________________________
firma del paciente
fecha
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
& Motor Vehicle Collision General Precautions and Instructions
Yo, _______________________ (tu nombre), Reconosco que yo e recibido, revisado, entendi
comprendido y, estoy de acuerdo con el aviso de practicas de privacidad de Enterprise Chiropractico y
Motor Vehiculo Colision General Precaucion y Instrucciones, cual describe el ejercer politica/ poliz
procedimiento con rescoto a el uso y revelacion de cualquier de mis informacion de salud protegerla
creado recibida o mantener por la y proporcionar instrucciones para cuidado en casa.
X_____________________________________________________________________________________
firma del paciente
fecha
__________________________________________________________
Print Name
Uso para oficina solamente
The Practice has made a good-faith effort to obtain an acknowledgement of ________________________’s receipt of our Notic
Privacy Practices. In an effort to obtain it, the Practice has attempted to provide patient with a Notice of Privacy Practices in
following manner: Personalmente correo Phone Follow-up otro __________________________________________
In spite of these efforts, the Practice has been unable to obtain a signed acknowledgement of receipt for the following reasons:
paciente no esta disponible paciente fisicamente no puede pacient no esta dispuesto. Firma/ fecha
14
IRREVOCABLE DOCTOR’S LEIN
AND ASSIGNEMNT OF RIGHT TO RECOVERY
Name: _________________________Date:
____________________
________________Claim
Number:
En consideracion y intercambio para que no tengas que pagar tu deuda inmediatamente y
en consideracion recidiras en el futuro cuidado en o por la clinica y el doctor en de quien de
quien letterhead en este document esta imprimido (hereinafter “clinica”), Yo, el lo abajo
firmante, por esto asignar y trasmitir a la clinica un legal y equitable interesen cualquier y todas
la causa de accion o derechos de recuperacion yo puedo haber surgido/presentarse fuera de ese
cierto accidente o lesion-producir/ fabricarze acontecimiento que ocurra/sucede en o
sobre_______________ , a la lleno alcance de el costo y tratamiento proporcionado o va hacer
proporcionado a mi por la clinica.
Yo como resultado de esto autorizo y directo a mi abogado(s) con toda confiansa, y que
page directamente a la clinica la suma,cantidad que se deba a la clinica por tratamiento y otros
servicio professional prestados mi las dos por la razon de el accidente y por razon de cualquier
otras factures que se le dedan a la clinica y de retener tal suma desde cualguier ver,conceder y
transportar a otra persona con mi caso a la clinica contra cualquier y todo lo recaudado de
cualquier y todo causade accion, resolucion, fallo o veredicto cual se pueda pagar a o a traves de
mi abogado, or yo mismo, como resultado de mi lesion o condicion por la cual e ver tratado por
la clinica .
Si no abogado puede ser confiado con mi caso , Yo entiendo/comprendo que el seguro le
pagara directamente a la clinica por todos los servicios prestados como resultado de este
accidente y o cualquier otra factura que se deba.
Yo comprendo completamente que yo soy directamente y completamente responsable a
la clinica por todas las facturas contraer por servicios prestados a mi y que el acuerdo esta
hecho unicamente por la clinica para protection adicional y en consideracion contingente en
cualquier resolucion,fallo o veredicto por que yo pueda finalmente recuperar. Yo soy
personalmente responsable por mi factura, a pesar de todo i del cualquier resultado,afirmacion
legal o causa.
Yo comprendo completamente que si mi abogado(s) si o no protégé los interes de la
clinica, la clinica puede requerirme a mi que haga pagos en mi cuenta. La clinica tambien
puede traer provocar accion contra mi abogado(s) por fallar a honrar este vinculo y irrevocable
trato entre mi y la clinica
Yo ademas comprendo y estoy de acuerdo que la clinica no es responsable por el
honorarios de mi abogado y la clinica no esta de acuerdo en pagar los honorarios del abogado por
honor acuerdo entre yo y la clinica.
15
“I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT, AND I AM
VOLUNTARILY SIGNING THIS DOCUMENT. I AM DIRECTING MY ATTORNEY(S)
TO PROTECT THE CLINIC’S AND DOCTOR’S INTEREST AT TIME OF
SETTLEMENT, AND I AM ASSIGNING AND CONVEYING CERTAIN LEGAL
RIGHTS TO THE CLINIC. I ALSO KNOW I MAY NOT REVOKE THIS AGREEMENT
AT ANY TIME WITHOUT PRIOR WRITTEN AUTHORIZATION FROM THE CLINIC.
I UNDERSTAND THAT, AMONG OTHER THINGS, THIS IS A BINDING AND
ENFORCEABLE CONTRACT, ASSIGNMENT AND LEIN.
_______________________________
X___________________________
_______________________
Imprimir Nombre paciente
Firma del paciente
Fecha
_______________________________
_______________________
Imprimir Nombre abogado /
Fecha
___________________________
Firma del Abogado/ Ajustador
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH
INFORMATION-RECORDS
Last name:
Home Address:
Date of Birth:
MI:
First Name:
City:
State:
Social Security/ID Number:
Zip:
The 1996 Health Insurance Portability and Accountability Act (HIPAA) require that all health care providers comply
with the patient privacy and security laws (45 CFR Parts 160, 164). Patient confidentiality and privacy/security applies
to any protected health information (PHI) contained within the medical records. Federal Law now require signed and
dated authorization from patients in several aspects of patient care, transmission of medical information,
confidentiality, and patient rights relating to their release of medical records.
LIST PURPOSE(S) FOR WHICH THE INFORMATION IS NEEDED:
___________________________________
AUTHORIZATION EXPIRATION. Without my express revocation, this authorization will expire 12 months from
the date signed: (1) upon satisfaction of the need for disclosure; (2) on date (supplied by patient)
___________________; (3) under the following conditions (examples: case closure, termination of plan benefits, ECT)
__________________________________________________________________________
RELEASE AUTHORIZATIONS (Patient, please initial the following section(s) that apply to you.
______ Initial. Doctor/Medical Facility... I authorize release of entire set of my medical records including: intake
forms, history, diagnosis, treatment, consultation, neurological/laboratory/radiologic scan or test results, disabilities,
billing information, reports, correspondence, and medical records from other sources to the following
doctor/facility/person:
List Name/Address: _____________________________________________________________________
______ Initial. Insurance-Medical Plans. I authorize said doctor to communicate with, send updated billing, reports,
and release all medical records necessary to process this claim to the following insurance companies and/ or
governmental agencies listed below:
List: _________________________________________________________________________________
______ Initial. Attorney. I authorize said doctor to communicate with my retained attorney (paper, electronic, and
oral). I further authorize the release of reports, all medical and treatment records, billing records photos, and other
records necessary to process my claim. This authorization is valid until the case is closed or at the conclusion of
litigation and said doctors bills have been fully paid.
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Name of attorney: ______________________________________, Date of Injury: ___________________
______ Initial. Family/ Friend. I authorize said doctor to communicate with the following friend/family member
about my health condition and recommendations. Name of person(s): ____________________
______ Initial □ Yes, □ No: [Special Limitations for Release of Sensitive Protected Health Information.] I
specifically authorize the release of HIV/AIDS test results, sexually transmitted or communicable disease notes ( such
as Hepatitis or venereal diseases ), drug, alcohol, or substance abuse or treatment notes, behavioral, mental health
disabilities or developmental disability, ( including mental retardation), abuse, neglect or domestic violence, sickle cell
anemia, government research, or genetic testing information. The recipient is prohibited from redisclosing such
sensitive PHI information without my authorization unless permitted by state and Federal law. List any other special
restrictions that you want limited (e.g., psychiatric/psychological records):
______________________________________________
AUTHORIZATION

I certify that this request has been made freely, voluntarily and without coercion and that the
information is accurate.

I voluntarily authorize and request that my health information (including paper, oral, and electronic
interchange) be release to the above sources as set forth on this form.

I can revoke this authorization at any time by giving my written revocation in writing to said
doctor’s office. My revocation is not effective as to disclosures already made and actions already
taken in reliance upon this authorization

The disclosing health care provider/plan/may NOT condition treatment, enrollment in the health
plan or eligibility for benefits on whether I sign this authorization.
Information disclosed under this authorization may be rediclosed by the recipient and may no
longer be protected by federal and state law.


I have the right to request a list of doctors, facilities, and/or government agencies which have been
sent my medical records.
___________________
X______________________________________________________________
(Date)
(Signature of Patient)
___________________
_______________________________________________________________
(Date)
(Signature of person authorized by law)
REQUEST FOR MEDICAL RECORDS
PATIENT NAME: ______________________________________ DATE:
__________________________
Patient
Identification:
Social security:
Medical record No:
Date of Birth:
Request Records From (Name and address of Doctor/ Facility where patient’s medical records are presently
located):
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Name:
Address:
SEND THE SPECIFIED AND AUTHORIZED MEDICAL RECORDS TO:
Doctor’s Name:
Address:
Telephone:
Dr. Albert Noble D.C. Enterprise Chiropractic Clinic
10576 SE Washington St, Portland, OR, 97213
503-252-5320
WHAT MEDICAL RECORDS ARE AUTHORIZED TO DISCLOSE AND MAIL:
□ All Medical Records
□ X-Ray/MRI/CT reports
□ EMG, SSEP, Nerve Conduction, Laboratory tests, Diagnostic Test Report.
□ Other
_______________________________________________________________________________
SPECIFIC DATES AUTHORIZED FOR RECORDS RELEASE
Medical records from (insert date) _________________ to (insert date) _________________________
PURPOSE OF RELEASE OF INFORMATION
□ At request of above patient
□Other:
I hereby request and authorize disclosure of the above protected health information in my medical records kept at your office or
facility to be photocopied, released and mailed to above doctor/facility at the indicated address for the specified dates. I
understand that the Health Insurance Portability and Accountability Act (HIPAA) apply to my medical records and protected
health information. I expect the holder of my medical records to mail my specified medical records as soon as reasonably
possible, not to exceed 30 days if kept on-site, and 60 days if stored off-site, once this request has been received. This
authorization may be revoked by me, at any time, by advising the doctor’s office (privacy officer) of this revocation in writing,
except to the extent a source of information has already relied on it. I have been advised that if I choose to not sign this
authorization that it will not have any adverse effect on my treatment, eligibility for benefits, enrollment, or payment.
EXPIRES: This authorization is good for 12 months from the date signed for the disclosure of the
information
described above.
*This authorization does not apply to any record/notes regarding HIV/AIDS, communicable disease,
alcohol or drug treatment, mental health information, behavioral health care, domestic violence, genetic
testing, and psychiatric or psychotherapy notes.
PATIENT NAME (Print clearly):
____________________________________________________________________
INDIVIDUAL AUTHORIZING DISCLOSURE (Signature): ____________________________ DATE:
________________
If not signed by patient, specify basis for your authority to sign: □ Parent of minor, □ Guardian
This general and specific authorization to disclose was developed to comply with the provisions regarding
disclosure of medical information under HIPAA: 45 CFR Parts 160and 164, 42 CFR part 2, 38 CFR parts 99 and
300, and State Law.
18
PATIENTS COPY
ENTERPRISE CHIROPRACTIC
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU
MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION.
PLEASE REVIEW IT CAREFULLY
Our practice is dedicated, and we are required by applicable federal and state laws, to
maintain the privacy of your health information. These laws also require us to provide
you with this Notice of Our Privacy Practices, and to inform you of your rights, and our
obligations, concerning your health information. We are required to follow the privacy
practices described below while this Notice is in effect. This Notice is effective as of
04/15/03, and will remain in effect until we replace it.
CHANGES TO NOTICE:
We reserve the right to change this Notice and the Privacy Practices described below at
any time in accordance with applicable law. Prior to making significant changes to our
Privacy Practices, we will alter this Notice to reflect the changes, and make the revised
Notice available to you upon request. Any changes we make to our Privacy Practices
and/or this Notice may be applicable to health information created or received by us prior
to the date of the changes.
You may request a copy of our Notice at any time. For more information about our
Privacy Practices, or for additional copies of this Notice, please contact us using the
information listed at the end of this Notice.
PERMITTED USES AND DISCLOSURES OF HEALTH INFORMATION:
A. TREATMENT, PAYMENT, and HEALTH CARE OPERATIONS: You should be
aware that during the course of our relationship with you, we will likely use and disclose
health information about you for treatment, payment, and health care operations.
Examples of these activities are as follows:
 Treatment: We may use or disclose your health information to a physician or
other healthcare provider providing treatment to you.
 Payment: We may use and disclose your health information to obtain payment
for services we provide to you.
19
 Healthcare Operations: We may use and disclose your health information in
connection with our healthcare operations. Healthcare Operations include quality
assessment and improvement activities, reviewing the competence or
qualifications of healthcare professionals, evaluating practitioner and provider
performance, and other business operations.
B. AUTHORIZATIONS: You may specifically authorize us to use your health
information for any purpose or to disclose your health information to anyone, by
submitting such an authorization in writing. Upon receiving an authorization from you in
writing we may use or disclose your health information in accordance with that
authorization. You may revoke an authorization at any time by notifying us in writing.
Your revocation will not affect any use or disclosures permitted by your authorization
while it was in effect. Unless you give us a written authorization, we cannot use or
disclose your health information for any reason except those permitted by this Notice.
Name: _________________________Date:
____________________
________________Claim
Number:
C. DISCLOSURES TO FAMILY AND PERSONAL REPRESENTATIVES: We must
disclose your health information to you, as described in the Patient Rights section of this
Notice. Such disclosures will be made to any of your personal representatives
appropriately authorized to have access and control of your health information. We may
disclose your health information to a family member, friend or other person to the extent
necessary to help with your healthcare or with payment for your healthcare only if
authorized to do so. In the event of your incapacity or in emergency circumstances, we
will disclose health information based on a determination using our professional
judgment, disclosing only health information that is directly relevant to the person’s
involvement in your healthcare.
D. MARKETING: We will not use your health information for marketing
communications without your written authorization.
E. USES OR DISCLOSURES REQUIRED BY LAW: We may use or disclose your
health information when we are required to do so by law, including for public health
reasons (e.g., disease reporting). In some instances, and in accordance with applicable
law, we may be required to disclose your health information to appropriate authorities if
we reasonably believe that you are the possible victim of abuse, neglect, or domestic
violence or the possible victim of other crimes.
F. PATIENT AND THIRD PARTY PROTECTION: Only as permitted by law, we may
disclose your health information to the extent necessary to avert a serious threat to your
health or safety or the health or safety of others.
20
G. LAW ENFORCEMENT / NATIONAL SECURITY: Under certain circumstances
we may disclose health information relating to members of the Armed Forces to military
authorities. Under certain circumstances we may also disclose health information
relating to inmates or patients to correctional institutions or law enforcement personnel
having lawful custody of those individuals. We may disclose health information in
response to judicial proceedings and law enforcement inquiries as permitted by law and
to authorized federal official’s health information required for lawful intelligence,
counterintelligence, and other national security activities.
H. APPOINTMENT REMINDERS: We may use or disclose your health information to
provide you with appointment reminders (such as voicemail messages, postcards, or
letters).
PATIENT RIGHTS:
 ACCESS TO RECORDS: Upon submission of a written request to us, you have
the right to review or receive copies of your health information, with limited
exceptions. You may obtain a form to request access by using the contact
information listed at the end of this Notice. You may request that we provide
copies in a format other than photocopies and we will use the format you request
if it is readily available. We will charge you a reasonable cost-based fee relating
to the production of such copies. If you request copies, we will charge you $0.25
for each page, and postage if you want the copies mailed to you. If you request an
alternative format, we will charge a reasonable cost-based fee for providing your
health information in that format. If you prefer, we will prepare a summary or an
explanation of your health information for a fee. Contact us using the information
listed at the end of this Notice if you are interested in receiving a summary of
your information instead of copies.
Name: _________________________Date:
____________________
________________Claim
Number:
B. ACCOUNTING OF CERTAIN DISCLOSURES: Upon written request, you have the
right to receive a list of instances in which we, or our business associates, disclosed your
health information for purposes, other than treatment, payment, healthcare operations and
other activities authorized by you, for the last 6 years, but not before April 14, 2003. If
you request this accounting more than once in a 12-month period, we may charge you a
reasonable, cost-based fee for responding to these additional requests.
C. RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You have the right
21
to request that we place additional restrictions on our use or disclosure of your health
information for treatment, payment and healthcare operations purposes. Depending on
the circumstances of your request we may, or may not agree to those restrictions. If we
do agree to your requested restrictions, we must abide by those restrictions, except in
emergency treatment scenarios. You have the right to request that we communicate with
you about your health information by alternative means or to alternative locations (e.g., at
your place of business rather than at your home). Such requests must be made in writing,
must specify the alternative means or location, and must provide satisfactory explanation
how payments will be handled under the alternative means or location you request.
D. AMENDMENTS TO RECORDS: You have the right to request that we amend your
health information. Such requests must be made in writing, and must explain why the
information should be amended. We may deny your request under certain circumstances.
E. ELECTRONIC NOTICES: If you receive this Notice on our Web site or by
electronic mail (e-mail), you are entitled to receive this Notice in written form as well.
QUESTIONS AND COMPLAINTS:
If you want more information about our Privacy Practices or have questions or concerns,
please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with
a decision we made or any decision we may make regarding the use, disclosure, or access
to your health information you may complain to us using the contact information listed
below. You also may submit a written complaint to the U.S. Department of Health and
Human Services.
Please direct any of your questions or complaints to:
CONTACT:
FAX:
E-MAIL:
Dr. Albert Noble, Enterprise Chiropractic Clinic
503-639-2052
[email protected]
MOTOR VEHICLE COLLISION GENERAL PRECAUTIONS AND INSTRUCTIONS
22
PATIENT: ______________________________________________________DATE__________________
Strong and very rapid forces may be involved in your automobile accident. It is important that you watch for any new
symptoms that might be a sign of hidden injury and/or increased inflammation. It is normal to feel soreness, pain, and
tightness in your body, often getting worse the second or third days. However, more severe pain and new symptoms
such as numbness, tingling, balance issues, and weakness in your arms and legs should be reported to your doctor as
soon as possible. Although you may have a lot of soreness, stiffness, and/or pain, most people recover over time.
As a result of a motor vehicle collision, some people feel a general sense of stress or anxiety which can lead to trouble
sleeping or irritability. Some people feel like avoiding driving in vehicles for some time. In the majority of cases, these
feelings go away within a few days or weeks.
AVOID NEW INJURIES
it is important for the first week or two weeks to avoid any high-risk physical activities or contact sports that may reinjure you and case new injuries. Avoid excessive jarring activities or extreme physical activities, such as heavy lifting.
HOME CARE
It is important to comply with the home recommendations that the doctor gives you. Your doctor will be giving you
advice about how important it is to keep physically active during the healing process.
 Do not sit-up in bed watching TV or reading or sit on soft couches. Firmer chairs are advised.

Avoid twisted positions with your neck and back

Lie on the floor or bed with your legs and knees bent with a pillow under your knees to reduce back pain

Change your body position every 30 minutes for the next week

Do slow and gentle stretches 4-6 times a day for 1-2 minutes. Do not push into moderate or severe pain.
Stretches can include sitting shoulder rolls, lying on the floor and gently holding each knee to the chest, and
general flexibility motions for the neck and back. As you feel better the stretches can be increased.

Take short walks every day (start with level surface) for 5-10 minutes and repeat 3-4 times each day. Work
up to longer walking periods and gradually increases your walking speed and time. The goal is to get you
walking an hour a day. Once you feel better then you can walk up hills.

Avoid sitting/standing or any awkward positions for prolonged periods for the next two weeks.

Use good posture and proper body mechanics over the next few weeks.

Getting an extra 30-60 minutes of extra sleep a night is recommended for the first week. Make certain to get
restful sleep.

Use ice for the 3-4 days. Place a thin towel between the ice pack and your skin and keep the ice on for the
prescribed length of time. Do not fall asleep with ice pack on. Neck use ice for 10-15 minutes and the back
use 20-30 minutes.

GOALS OF THIS OFFICE
The primary goal of this office is to restore your ability to return to your normal pre-injury physical activities of daily
living; including work, home, sports, and recreational activities. Our office focuses on improving joint and soft-tissue
function by providing appropriate therapies to injured areas and thus assisting your body in healing and reducing pain
levels and aiding your recovery. Your active participation at home and work is important in the recovery process and
your compliance with the appointments and exercise recommendations will improve your outcome.
MONITORING YOUR PROGRESS IS IMPORTANT TO OUR OFFICE
23
Our office staff will periodically ask you to fill out addition paperwork that is designed to document your response to
spinal manipulation and other therapies/procedures and your responses allow our office to determine if your treatment
outcome is on track, if your treatment needs to be changed or modified, if further testing is indicated, if a consultation
by another health care provider is needed, or if a referral is indicated.
FOLLOW-UP APPOINTMENTS
it is important that you keep all of your appointments and follow all home instructions, including exercise, stretching,
use of ice, and watching your posture. Call your doctor if you have any problems. If you miss or do not show-up for
two appointments, our office will need to talk to you about your absence and find some way to work with your
schedule. If four scheduled appointments are missed the office may refer you to another provider, depending upon
circumstances.
24
Name:_________________________Date:________________Claim
_____________________
Number:
DYANOMETER LECTURA
Mano isquierda
1.) ________________________
________________________
Mano derecha
1.)
2.) ________________________
________________________
2.)
3.) ________________________
________________________
3.)
Promedio para la mano isquierda:
Promedio para la mano derecha :
25
PHYSICAL EXAMINATION
Altura: ___________ Peso: ___________
Fecha de llamada:
EMPLEADO:
B.P. ____/____Pulso: ___________
ECC VERIFICAR NOMBRE DEL
MVA PIP Coverage Questions:
Is this a third party insurance or is this the patient’s personal insurance? Third party
Personal
(Third Party is only accepted if the injured is not at fault, but has
no personal insurance)
If you answered third party to the above question; did the other insurance company
accept liability?
*If third party, you must send the signed Doctor’s Lien to the adjuster (or lawyer if they
have one) and have them sign it and send it back to us*
Nombre del paciente :
Fecha de nacimiento: _________________________
Fecha de la lesion:
Hablates con:
Numero de reclamacion:
Numero de poliza (Opcional):
PIP Adjuster Name:
Numero de telefono w/ext.:
26
Numero de fax:
Medical PIP disponible y esta abierto?
A que direccion nosotros mandamos/enviamos la factura?
Yo verifique y contacte la compania de seguro en la fecha:
.
Firma:
.
*Grupo de gente en el mismo carro juntos so you can ask all the questions on the same phone call.
*PIP coverage is through your own insurance no matter who is at fault in the ac
27